ACOG has created a survey, now members only, asking OBs to tell them if they have had homebirth transfers and what their outcomes were. I wish I’d copied the exact wording, but it was something to the effect of, “We know that we have to take homebirth transfers, but it puts us in an unfortunate place of cleaning up the midwife’s mess and is including our being sued when the midwife should be the one being sued, not us. Please fill out this short survey so we can demonstrate how pervasive this problem is.”

The questions included gravidity, parity, how long the woman was in labor before the transfer, what she was transferred for (prolonged rupture of membranes, meconium staining, fetal heart tone problems, uterine rupture, etc.), how it was resolved by the OB and who the care provider was in the home (CNM, CPM, unlicensed midwife or no one but the family [UC]).

When us crazy natural birth folks got wind of this, we dashed to the website during its brief public moment and filled it out for our own births. As a midwife, I also filled it out for my July baby, a wonderful home-waterbirth. I know the HBAC women flocked there, too. While I wish we’d had longer to make an impact, I love that we did make one so graphically that they felt they had to block us out. We are some noisy women! Hurrah for us!

Some women in Facebook were summarizing the request as trying to show the negative outcomes of homebirths, but I believe the goal was slightly different.

Doctors and nurses have long felt midwives bring in “train wrecks” that they are then responsible for cleaning up. Using me as an example, when I transported the surprise breech baby and they had to do an emergency cesarean, in the woman’s records, it said it was a failed attempt at a breech delivery. They never let me give report, never asked me what happened; they didn’t care. They saw it as a completely negligent action of a Licensed Midwife. Of course, I saw it as asking for help with a situation that was out of my scope of practice and skill level. When I had the 11-pound HBAC that hemorrhaged and I transported her, I could see the doctor tsk tsking off to the side, feeling, “Here I go again with the mop soaking up the blood that midwife caused.”

I can see the doctors’ point of view on several levels. What has happened is some of the women who have transferred to the OB’s care have had negative outcomes and sued the doctor. That has to be incredibly frustrating for them. Where does the line between midwife negligence and doctor negligence lie? If a midwife transfers for thick meconium and the OB monitors the baby, doing a cesarean after a few hours, only when the baby showed signs he was having some distress… and the baby has Meconium Aspiration Syndrome (which we know now happens in utero more times than out)… and the parent decides to sue, who gets sued? Whose responsibility was the MAS? If you believe as I do that no one was responsible, that isn’t the point. A mother with a sick baby tends to want to blame someone; who gets it?

What I think happens is that doctors are sued much more because of the relationship aspects a midwife develops with her clients. It has long been known that women rarely sue their midwives. If anyone sues midwives, it is the State. But, for a homebirth family, the doctor is an unwilling scapegoat.

Is there anything a midwife can do to keep these types of lawsuits from happening? They really tarnish the homebirth community. Of course, if the doctor was negligent, that is one thing, but is a midwife big enough to say, “I don’t think anyone could have seen this happening,” or even “I’m sorry this happened; I did exactly what I knew to do and transported you as soon as I saw things were outside the realm of normal.” Is it a midwife’s responsibility to help her client-family see the truth of the situation?

I wish they would have put some of their examples up. I haven’t yet seen one of these lawsuits, one that straddles the responsibility of midwife and OB. I’d love to hear any so we can take it apart and see the dilemma the OBs speak of.

While we all are thrilled with our wonderful homebirths and so many of us got our voices heard on their site yesterday, it is important to remember they have a reason, a valid reason, for wanting to hear from their constituency. Perhaps a midwifery organization could do something similar, asking, “When you transfer a client to the hospital, what do you transfer for? How were you treated by the nurses? OBs? How was your client treated? What was the outcome? Did the nurse or OB say anything directly to you or your client regarding this being a complication of homebirth? How does your client feel about her complete transfer experience?”

I’m sure there are more questions that need to be asked. Let’s ask them. It isn’t only ACOG that can do surveys.

Reader Comments (17)

FYI - their survey was cached, here is the wording on the original survey (now pulled in the members only section).

" The American College of Obstetricians and Gynecologists is concerned that recent increases in elective home delivery will result in an increased complication and morbidity rate. Recent reports to the office indicate our members are being called in to handle these emergencies and in some instances have been named in legal proceedings. To attempt to determine the extent of the problem, a registry of these cases will be maintained at ACOG on a year-by-year basis.

If you have been called to attend, whether in the emergency room, operating room or labor and delivery suite, a patient who came to your hospital after an unsuccessful attempt at elective home delivery, please complete the following survey even if there was no adverse outcome. Include only current events after June 15, 2009. "

What I have an issue with this, is the assumption that all transfers in are due to negligence on anyone's part, and that they don't list as a reason for transfer things like Maternal Exhaustion, or Pain Medication. I would think that these are perfectly acceptable reasons for a transfer that doesn't have to 'cleaning up' anyone's mess. I started work as a birthworker in a state that was terribly accepting of the homebirth movement, and as such, transfers weren't regarded with such disdain. It was seen as a simple 'outside of my scope of practice, can you help us with this?' It goes back to a, why can't we all get along? mentality. Truly, I love some OB's. I really do. They are wonderful tools, experts in surgery and trained to help in situations we are not. I just wish they would stop viewing homebirth transfers as a failure. Because they aren't.

This issue of determining who is at fault has always been an interesting one to me. I mean you can't name Mother Nature in a lawsuit. And a lot of times, when Dr's are sued, I do feel badly for the circumstances on BOTH sides. Are there indicators for things that cause fetal demise, or handicap? Sure. But sometimes, for perfectly acceptable reasons, those things aren't caught. By ANYONE.

I don't know. Good post, I agree with everything you said. I would love to hear about the cases of good transfer and reasonable causes for seeking out a Dr. Not just the train wrecks. It's inevitable that as a midwife, I will have to transfer into a hospital. But even under the worst of situations, it doesn't and shouldn't need to be viewed as a train wreck, or cleaning up someone else's mess.

What an interesting way that they put it. But I guess if you're personally taking responsibility (as a CP) for the good outcome of a birth, then on the flip side you'd have to feel that some one was responsible for a bad outcome. Now I'm sure there certainly are times when a midwife has mis-managed a complication that lead to a transfer, but it really seems like they're targeting midwives more than just homebirth by looking at it from the angle "How could the midwife have prevented this?". Ignoring that in the hospital or out, complications do arise.

Funny how doctors are all about how DANGEROUS birth is, until it's a transfer, and then of course it was negligence on the part of the midwife!

If only doctor's could "see" and do surveys on the totally normal/straight-forward births that they themselves have made "train wrecks" out of w/ their own two hands by simply practicing medicine they do. It seems there would be more to be gained by that than trying to hunt down more negative transfer stories.

I totally understand that the grand majority of births we bring into the hospital are transFERs not transPORTs (a transfer is bringing her in in the family car... transport is via 911) and that, by far, they are not "train wrecks" - but you do admit, when it's bad, it's BAD, otherwise we wouldn't be bringing her in via ambulance!

It is annoying how they see homebirth transfers, I agree. But I think the way to find some balance is in seeing it through their eyes for a minute. It is in this type of understanding that peace might be found. I know that when I have been in difficult situations, my being kind, thanking the doctors and nurses for their care, has helped a lot. When they are continually hateful, nothing I could say or do would make a difference, so I sigh and sit quietly, hold her hand, and let them take care of my client.

Now, if the DOCTOR could take half a second and see OUR point of view, they might get the hint *why* they are sued. Their brusque manner, crude treatment and those being steeped in an attitude of disdain all makes for a great medium called Lawsuit.

It's this standing miles away with our backs turned on each other that gets us nowhere.

What I do not like about the pretense of this survey is that it reinforces the "godlike" mentality of Doctors. If I go to a Doctor, he will SAVE my baby & I will have a perfect pregnancy & baby. Now we all know that is not true, and even Doctors themselves know that is not true, but many people believe it. I even hear it from many in my club, the dead baby club, that lost their babies at or during a home birth/birth center birth. If I had only been in the hospital, my baby would not have died. We know that this is not true. Continuous monitoring does not save babies or make for better outcomes, but many would like believe that this is true. It is a false sense of security. Anyway, that is my 2 cents!!!

"Now, if the DOCTOR could take half a second and see OUR point of view, they might get the hint *why* they are sued. Their brusque manner, crude treatment and those being steeped in an attitude of disdain all makes for a great medium called Lawsuit.

It's this standing miles away with our backs turned on each other that gets us nowhere."

Not intended personally toward you Barbara and this probably wont win me a popularity contest but if we want to help physicians 'see' our point of view, and if turning our backs on one another is getting us nowhere I'm hard pressed to believe that sabotaging their seriously flawed data collection efforts is going to bring the result we are seeking either.

I just don't see how this was helpful. I'm ashamed to admit I can see why it might be kind of fun though :)

I saw this as more an opportunity for the midwifery advocacy groups to forward a formal, thoughtful and well articulated statement to ACOG.

Resolving professional conflict through antagonism is generally unsuccessful. I just don't know that it accomplished anything in terms of increasing the odds of being heard or decreasing the existing hostility these groups appear to have for one another.

I have a couple thoughts on this. Is it possible that one reason doctors are sued so often for birth injuries is because the medical expenses for caring for that child become really high and there is no universal health care to foot the bill? In countries with universal health care, are there as many lawsuits for birth injuries?

Also, could it be that midwives are not sued as often because they don't have as much malpractice insurance, and if you are going bankrupt with health care bills, why wouldn't you go after the doctor and hospital where the money is? Lawyers are practically knocking down women's doors to take these cases, as they are usually a sure thing, and I am sure they are not going to pursue action against someone who is not going to pay the bills.

And my last point, is it possible that midwives are sued less often because they offer a woman the option of true informed consent and refusal far more often then an OB would? If a midwife allows the mom to decide, and there is a bad outcome, then the mom feels she was partially responsible for the decisions that led to that outcome (not that it is her fault, or anyone's fault, but she may be able to see that more clearly when there isn't someone obvious to blame). OB's generally do not allow women their legal rights to informed consent and refusal, and they coerce, manipulate or force women into the choices they decide for them. It is far easier to want to sue someone who made the decision for you without first explaining the risks of the procedure or intervention. Ironically, when lawyers fight these cases, they are fighting them based on a risk not being explained, or an alternative not being offered, and they generally win. So what would protect OB's from lawsuits is the same thing that protects midwives from lawsuits (more often then OB's anyway), and that is offering women their rights to informed consent and refusal of care.

The book "Baby-Catcher" has such a story. The woman had wanted a home-birth but became high-risk so was told a hospital birth was her only option; so she asked her midwife (the author) to become her doula. When the woman called her saying her water broke, the midwife went over, found thick mec and almost no heartbeat (occult cord prolapse). They transferred (ambulance got lost, so it took a veerrry long time; the midwife was holding the baby's head off the cord the entire time); went for an emergency C-section, tried to resuscitate the baby -- ten minutes, and nothing, so the attending OB, the head honcho keeps ordering resus, and finally at 12 minutes the baby begins breathing. A vegetable; minimal brain function, but alive. The woman sued the mw, her backup OB (she claimed he didn't tell her she *had* to go to the hospital because of her risk level), the hospital, and the staff there. Her malpractice insurance company forced her to settle (saying if the plaintiff's suit was successful, and the jury found for more than the settlement, she would have to pay the difference; and with the strong sympathy factor of the baby who could only scream but almost no other function, would have a very high risk of a very big judgment). So she settled, and the insurance company declined to renew her coverage because she had settled.

An alternate story happened a few years ago (the baby's name was Lucian, and the mother was not married -- the only things I remember, if you wanted to find the story) -- the baby was breech, and her only "choice" in the hospital was a C-section, so she jumped to homebirth care. The midwife laid out the risks, and her past previous breech births, and the woman chose home birth. The baby's head got stuck, the midwife couldn't get it out, the ambulance people couldn't get it out, finally after some 20 minutes I think the doctors were able to get it free, but of course the baby was dead by then. The mother didn't sue anyone, saying it was her choice to give birth as she did, and defended her midwife most heartily, because the OB community was trying to get the midwife investigated criminally, yada, yada, yada.

But, Cristina, no there is no guarantee that a hospital birth might have saved a baby, but I understand the attempt at believing one did everything possible - and when we birth out of a hospital, we (seem to) have *not* done everything possible. Conversely, we have heard MANY women say, "If I hadn't been in the hospital, this/that/the other thing wouldn't have been done." Having an out of hospital birth *requires* admitting not all services of a hospital are possible at home. It *requires* women to weigh the risk and the benefit - and if the benefit outweighed the risk and something happened, I believe it is appropriate to say, "If only I had been in the hospital." As someone who knows both continuous monitoring and intermittent monitoring, unless the midwife is extremely skilled in monitoring with a doppler, listening before and after contractions occasionally, listening for decels (which can be minute) or flat (which takes time to catch), the continuous monitoring *can* catch more. It is standard in my community to listen to heart tones once an hour until very active labor gets going, even then, they tend not to be every 15 minutes as we are supposed to do, unless we detect a problem, then *we* do continuous monitoring ourselves, using that information to make a decision about what to do next.

I would absolutely say, "If I had been in a hospital...." if I lost Meghann during my UC. I would have also said, "If only I'd have had a midwife there." It is why, in my experience, every woman who has a dramatic/deadly UC has a midwife or births in the hospital for a subsequent birth. Cristina, use yourself as an example and you will understand what we all mean.

Michelle: When I saw that people were demonizing ACOG and misunderstanding what they were trying to say/do, I tried to correct it. However, I felt it was important to put our 2 cents in on their poll, knowing full well they would close it down as soon as they saw what was happening. It is VERY important for ACOG to know we are watching/listening to what they say and do. It is really important for them to know we won't just wither away and blow like leaves in the wind. Part of why I wrote this post was to correct the belief that they were trying to skew the results of homebirth transfers; they weren't doing that at all! They were looking at WHY they happened and how they could keep their asses out of court with a homebirth transfer. I don't blame them in the least.

Jennifer: This morning, Sarah said to me that doctors make infinitely more than midwives do because they have an entirely different set of skills. She said they need to suck it up that we bring complicated cases in because we have run through our skills and we are now depending on theirs. They have malpractice insurance; most of us don't. They are sued; most of us aren't. LISTEN UP, ACOG!

But, I also need to say, on the heels of what I said above, that when we transfer to the hospital, *because* we have run through my set of skills in birth, options pretty much go out the window. There no longer is the request of intermittent monitoring, no IV, etc. I am there to help with the choices that *can* be made, but they are pretty much moot. The risk/benefit process becomes a charade, so I believe it is almost cruel to dangle a carrot they can never reach. HOWEVER, what the transferring midwife's job is to give the information as far in advance of what will happen as possible. I've written before about what a transport dialogue would sound like, but that banter continues throughout the emergency experience in the hospital. If mom transfers for maternal exhaustion (or some other sort of benign reason), the options are still pretty sparse. I think it is a midwife's responsibility to talk about that during the pregnancy. It can help a woman make the choice of stay or go if she's waffling during labor (and it isn't emergent).

Barb, I was totally agreeing with you in my original post! We are not the deciders of who lives & who dies. We are not God/Goddess. We do not have that power. What we have is knowledge & skill. Hopefully that knowledge & skill can give us what we need to have successful birth, but we have no control. And neither do doctors with all their technology, obviously. We have more technology today than ever & more babies dying every day. We are on the same page, but maybe my words did not express that???

Long time blog reader here....This reminds me of the comparison someone made about the man that owned a Ford repair shop. All this man did was repair broken down Fords. He thought Fords were horrible cars, because they had so many problems and everyone had their dang Fords brought in to be fixed. What he didn't see were the millions of perfectly functioning Ford cars out on the road. When I read the comparison (and I can't remember the author), it sounded much better, but you can get what it is about : ) ALL the doctors see are the problems that they have to fix! They don't see the thousands upon thousands of beautiful homebirths that we know happen. Thanks for the blog!

I am NOT a healthcare professional, so I am truly asking a question here...Aren't all midwives mandated to have a physician backup? I know my midwife shares a practice with a wonderful OB who follows the midwife model of care (a rarity, I know). I thought that was standard practice. It seems to me if there were a working relationship between the transferring midwife and the receiving OB, that a lot of the tension would be minimized. But I really don't know about that part of the "business."

Not all midwifery laws require physician back-up; some say physician collaboration, which removes some of the legal responsibilities of the doctor.

Here in CA, yes, it is in the law that we have to have OB back-up, but, the docs' insurance/malpractice company has said they will cancel any OB's insurance -and remove it for the previous 3 years- if they back-up a midwife. Only a very, very few have what anyone would call "back-up." LMs have tried to get the law changed to the word "collaboritive" instead of "supervisory" so we can at least consult with doctors. As it stands, if we check in with a doctor about a case, it cannot be charted as such, lest the doctor get him/herself in a net that can cause them to lose their insurance.

So, LMs are left in a weird position; required to have OB back-up, but the OB's forbidden to give it. The Medical Board of CA acknowledges the dilemma and the midwives I have known to be investigated, this is one of the issues addressed in complaints, but has been routinely "dropped" from the complaint.

How lucky is your midwife! I wish we could have that kind of relationship with our doctors. Very sad that we cannot.

NGM- I am trying to combat the lies spread by those who are against homebirth. There are a few things I agree with them on but I think they are doing more harm then good. I feel that they are using the excuse that homebirth is "dangerous" only to berate those of us who have chosen homebirth and to demonstrate that they are "the better mother" for giving birth in the hospital. I had very valid reasons for choosing homebirth as I am sure other women do. I hope you check out my blog. I would love to have your input. I want to write a post about the truth about CPMs. Are they really as dangerous and uneducated as they like to present? I have a lot to look into, I want to learn as much about CPMs as I can because if they are lying about them, than they are creating a lot of harm. Sammy

See, Sammy... you don't know me very well because if you did, you wouldn't be asking me to help you in your cause.

While I am not against homebirth or homebirth midwifery, I *am* against the ghastly level of education and skill necessary to become a CPM. I'm speaking out for mothers and babies from a midwife's perspective.

So, you might want to poke around someone's site a bit more before asking them to go see your site. And, it isn't the best Netiquette to slide in, drop your url and slide back out, so I removed your url from the comment.

After looking at your site, I *highly* encourage you to have someone great in English proof-read your posts. There are *several* grammatical errors that don't speak well about your seriousness for your cause.